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Based on staff interview, review of administrative/hospital policies and procedures and the infection control plan and documentation it was determined the hospital's chief executive officer (CEO) failed to effectively manage the hospital to ensure the infection control officer effectively enforced infection control policies and procedures (refer to A-0747, A-0748, A-0749 and A-0750). The CEO ' s failure to ensure the infection control officer implemented policies and procedures for control of infections in the hospital placed all patients, healthcare workers, and visitors at risk for healthcare acquired infections.

Findings include:

- "Governing Body Rules and Regulations" reviewed on 3/30/11 at 1:00pm directed the responsibility for managing and providing oversight of the hospital operations to the chief executive officer.

- Staff D, CEO, appointed by the Governing Body, interviewed on 3/30/11 at 11:30am indicated they were unaware the infection control officer failed to enforce the Infection Control Plan, policies and procedures and failed to report statistical information to the Safety Committee, Medical Staff and Quality Assurance committees. Staff D ' s management responsibilities for the entire hospital would include all components of infection control.

- Refer to citation A-0747 for further evidence; The CEO failed to manage the hospital effectively to ensure the hospital met the requirement for the Condition for Infection Control. Healthcare workers and the Infection Control Officer failed to follow the hospital ' s program, isolation procedures, or monitor and educate healthcare workers for the prevention, control and investigation of infections and communicable diseases.

- Refer to citation A-0748 for further evidence; The CEO failed to ensure the designated infection control officer implemented policies governing control and providing an active surveillance program of infections and communicable diseases for patient ' s and healthcare workers.

- Refer to citation A-0749 for further evidence; The CEO failed to ensure the infection control officer followed the infection control plan to maintain a system that identifies, reports, investigates infections and communicable diseases of patients and personnel.

- Refer to citation A-0750 for further evidence; The CEO failed to ensure the infection control officer maintain a current log of patients who had or developed infections in order to identify a trend or outbreak, and infections identified through employee health services, monitor patients who meet the CDC (Center for Disease Control) criteria for requiring isolation precautions during their hospitalization.

The failure to monitor and educate healthcare workers, monitor and track current patient infections to identify trends or outbreaks created a potential for healthcare-associated infections for both patients and healthcare workers.

Based on record review and staff interview the Hospital failed to ensure 2 of 3 patients (#'s 7 and 23) closed records contained discharge summaries the physician had signed, dated and timed within 30 days after the patient's discharge.

Findings include:

" Medical Staff Rules and Regulations " reviewed on 3/29/11 at 2:00pm directed medical staff to complete all medical records within 30 days following patient discharge. Review of the Medical Record Policy " Incomplete Records " , revealed, " ... records of discharged patients are completed within a period of time that in no-event exceeds 30 days following discharge."

- Patient #7's medical record reviewed on 3/29/11 revealed a discharge date of 1/20/11. Physician #7 signed the discharge summary on 2/28/11 or 38 days after the discharge. Physician #7 failed to sign the discharge summary as required within 30 days.

- Patient #23's medical record reviewed on 3/29/11 revealed a discharge date of 12/29/10. Physician #1 signed the discharge summary on 1/31/11 or 32 days after the discharge. Physician #1 failed to sign the discharge summary as required within 30 days.

Staff B interviewed on 3/30/11 at 1:00pm acknowledged physician # ' s 1 and 7 failed to sign the discharge summaries as required within 30 days.

Based on record review and staff interview the Hospital failed to ensure physician orders were signed, dated and timed for 14 of 38 (1, 2, 3, 4 ,6, 7, 15, 16, 17, 19, 21, 23, 24, 28) patient records reviewed and failed to ensure the physicians follow the Medical Staff Rules and Regulations.

Findings include:

" Medical Staff Rules and Regulations " reviewed on 3/29/11 revealed, under " 1.3-2: ... ....the attending physician shall date, time and authenticate the verbal order/telephone order for the hospital patient or by another physician who is responsible for the care of the patient and is authorized to write orders. "

- Patient #15's medical record reviewed on 3/29/11 revealed an admission date of 3/18/11 and a diagnosis of a fractured humorous. Physician #2 failed to date and time nine verbal orders and failed to sign, date and time five verbal orders between the dates of 3/18/11 to 3/29/11.

- Patient #17 ' s medical record reviewed on 3/29/11 revealed an admission date of 3/22/11 with a diagnosis of bronchitis. Physician #5 failed to date and time six verbal orders and failed to date and time three orders authenticated for the Advanced Registered Nurse Practitioner.

- Patient #28's medical record reviewed on 3/30/11 revealed an admission date of 2/25/11 with a diagnosis of aspiration pneumonia. Physician #1 failed to date and time seven verbal orders, physician #2 failed to date and time 28 verbal orders, and physician #3 failed to sign, date and time 17 verbal orders.

Staff B interviewed on 3/30/11 at 1:00pm confirmed physicians #1, #2, and #3 were not compliant with the date and timing of orders.

This deficient practice also affected patient's # 1, 2, 3, 4, 6, 7, 16, 19, 21, 23, and 24.

Based on staff interview, review of the hospital ' s Infection Control Plan, policies and procedures, 40 patient records, and observations it was determined the hospital failed to meet the Condition for Infection Control by ensuring healthcare workers and the Infection Control Officer followed the hospital ' s program for prevention, control and investigation of infections and communicable diseases. The hospital lacked a system for the prevention, control and investigation of infections and communicable diseases that included an active surveillance component the covered both hospital patients and healthcare workers in the hospital. The failure to monitor and educate healthcare workers, monitor and track current patient infections to identify trends or outbreaks created a potential for healthcare-associated infections for both patients and healthcare workers. The cumulative effect of the systemic problems in infection control resulted in the hospital ' s inability to ensure effective infection control to prevent healthcare-associated infections.

Findings include:

- The hospital designated infection control officer failed to implement policies governing control of infections and communicable diseases, and provide an active surveillance program that monitored and educated healthcare workers for compliance related to basic infection control practices with 5 of 5 healthcare workers (C, F, G, H, and I) observed performing eight skilled nursing cares. The failure to implement policies and procedures for control of infections in the hospital placed all patients, healthcare workers, and visitors at risk for healthcare acquired infections. See deficiency at CFR 482.42,(a), A-0748.

- The hospital failed to ensure the infection control officer followed the infection control plan to maintain a system that identifies, reports, investigates infections and communicable diseases of patients and personnel. The failure to identify 3 of 3 patients (#'s 9, 39 and 40) admitted with infectious diseases created a potential for healthcare-associated infections for both patients and healthcare workers. See deficiency at CFR 482.42(a)(1), A-0749.

- The hospital ' s infection control officer failed to maintain a current log of patients who had or developed infections in order to identify a trend or outbreak, and infections identified through employee health services, monitor patients who meet the CDC (Center for Disease Control) criteria for requiring isolation precautions during their hospitalization. The log failed to include 3 of 3 sampled patients identified during the survey with infections and on isolation precautions (patient # ' s 9, 39 and 40). The failure for ongoing monitoring placed patients and healthcare workers at risk for healthcare acquired infections. See deficiency at CFR 482.42(a)(2), A-0750.

Based on observations, staff interview, review of the Infection Control policies and procedures, and observation the hospital ' s designated infection control officer failed to implement policies governing control of infections and communicable diseases, and provide an active surveillance program that monitored and educated healthcare workers for compliance related to basic infection control practices with 5 of 5 healthcare workers (C, F, G, H, and I) observed performing eight skilled nursing cares. The failure to implement policies and procedures for control of infections in the hospital placed all patients, healthcare workers, and visitors at risk for healthcare acquired infections

Findings include:

- "Infection Control Program" reviewed on 3/30/11 at 10:00am revealed the hospital follows "CDC Guidelines" for infection control practices. CDC has defined "infection control professional" as "a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control."

- Observation made on 3/28/11 at 3:20pm revealed staff F failed to follow CDC guidelines for basic infection control practices. Staff F failed to wear gloves when performing an arm assessment to find a vein to start an intravenous (IV) needle on immune-compromised patient #22. Staff F failed to wear gloves during the needle insertion procedure; creating a possibility for the spread of infection to the patient and the healthcare worker.

- Observation made on 3/28/11 at 4:15pm revealed staff H failed to follow CDC guidelines for basic hand hygiene. Staff H entered the room of patient #21 removed a glove from one hand, walked into the patient's bathroom grabbed a fresh pair of gloves and put them on. Staff H failed to perform hand hygiene (wash hands with soap) between the glove changes. Staff H drew blood from the patient, removed gloves and left the patient's room. Staff H failed to perform hand hygiene (wash hands with soap) before leaving the patient ' s room; creating a possibility for the spread of infection to other patients.
- Observation made on 3/29/11 at 7:55am revealed staff G failed to follow CDC guidelines for basic hand hygiene and infection control practices. Staff G applied gloves to assess patient #8. Staff G failed to perform hand hygiene (hand wash or use the available alcohol foam) prior to the gloves being applied or after they were discarded. Staff G then went to the hall and obtained the blood pressure machine cart and took it to patient #8's room to measure vital signs. No cleaning/disinfectant wipes were on the cart for staff to disinfect the equipment. Staff G failed to perform hand hygiene (hand wash or use the available alcohol foam) before or after taking the vital signs. Staff G failed to disinfect the cart after use; creating the potential to spread infection to other patients.

- Observation made on 3/29/11 at 8:10am revealed staff C failed to follow CDC guidelines for basic hand hygiene when dispensing patient #41's medications. Staff C walked onto the unit, entered the medication area to dispense medication for patient #41. Staff C failed to perform hand hygiene (wash hands with soap or use alcohol foam/gel) before dispensing the medications. Staff C walked onto the unit removed a kleenex from their pocket blew their runny nose, put the kleenex back into their pocket and administered the medication. Staff C failed to wash their hands or use alcohol foam/gel after blowing their nose; creating the potential to spread infection to other patients.

- Observation made on 3/29/11 at 8:30am revealed staff R failed to follow CDC guidelines for basic hand hygiene when dispensing patient #5's medications. Staff R failed to perform hand hygiene (wash hands with soap or use alcohol foam/gel) before or after the medication pass; creating the potential to spread infection to other patients.

- Observation made on 3/29/11 at 9:00am revealed staff F failed to follow CDC guidelines for basic hand hygiene when they put gloves on to start an intravenous (IV) line in patient #8's left arm. Staff F failed to perform hand hygiene (hand wash with soap or use the available alcohol foam) prior to gloves being applied; creating the potential to spread infection to other patients.

- A random observation made on 3/29/11 at 4:10pm revealed staff G failed to follow CDC guidelines for basic hand hygiene when taking an IV bag of fluid to a patient room, hanging the IV bag, attaching it to the IV line and discarding the empty IV bag. Staff G failed to perform hand hygiene (hand wash or use the available alcohol foam) before or after the IV bag was replaced; creating the potential to spread infection to other patients.

- Observation made on 3/30/11 at 12:30pm revealed staff I failed to follow CDC guidelines for basic hand hygiene and infection control when they entered an isolation room with a " droplet precautions " sign posted on the door. Staff I failed to use the personal protective equipment placed outside of the room prior to entering. After hovering over the patient for a short period of time, staff I walked out of the room, left the door open, failed to wash their hands (or perform hand hygiene), and entered another patient's room creating the potential to infect the other patient.

Staff C interviewed on 3/30/11 at 10:00am acknowledged the hospital failed to have a active infection control program that monitored hand washing and failed to follow the hospital ' s policies to prevent the potential spread of infection to patients and staff.

Based on observations, staff interview and document review the hospital failed to ensure the infection control officer followed the infection control plan to maintain a system that identifies, reports, investigates infections and communicable diseases of patients and personnel. The failure to identify 3 of 3 patients (#'s 9, 39 and 40) admitted with infectious diseases created a potential for healthcare-associated infections for both patients and healthcare workers.

Findings include:

- "Infection Control Program", dated "2000", reviewed on 3/30/11 at 10:00am revealed the "Infection Control Officer" is to identify, report and investigate all infections and communicable diseases for patients and personnel.

- Patient #9's medical record reviewed on 3/30/11 at 7:00pm reveal an admission date on 3/23/11 with a diagnosis of possible pneumonia, urinary tract infection (UTI) and acute pharyigittis. Patient #9's admission laboratory culture results grew out Proteus Mirabilis (a species abundant in nature but that rarely grows in humans) in the urine and Methicillin Resistant Staph Aureus (MRSA - an infection-causing bacteria resistant to almost all antibiotics) in the patient's sputum. On 3/26/11 the culture result identified the patient was also infected with VRSA (Vancomycin-resistant Staphylococcus aureus, a strain of the bacterium Staphylococcus aureus). A review of physician orders revealed antibioticx ordered on 3/23/11 were IV (intravenous) Rocephin (an antibiotic), on 3/24/11 the physician discontinued the Rocephin and ordered IV Vancomycin (an antibiotic), then on 3/26/11 IV Tobramycin (an antibiotic).

Observation made on 3/28/11 at 2:30pm revealed patient #9's room had a sign posted on the door that identified the patient had infections which required all who entered the room to use isolation precautions.

Staff S interviewed on 3/30/11 at 8:15pm acknowledged that on 3/26/11 nursing documentation revealed the hospital transferred patient #9 to a dedicated isolation room and placed patient #9 on isolation precautions.

Staff C, infection control officer, interviewed on 3/30/11 at 10:00 to 11:00am acknowledged they were unaware of any current patients admitted with infections. Staff C failed to provide investigative documentation that identified inpatient #9 with transmittable infections, on antibiotic medications and isolation precautions.

Patient #39's medical record reviewed on 3/30/11 revealed an admission date on 3/28/11 with a diagnosis of acute pharyigittis and RSV (respiratory syncytial virus (RSV) is a virus that causes respiratory infections) positive. On 3/28/11 the physician ordered Ceftin (an antibiotic for an ear infection) and on 3/29/11 the physician discontinued the Ceftin and ordered Rocephin (an antibiotic).

Observation made on 3/29/11 at 8:00am revealed patient #39's room had a sign posted on the door that identified the patient had infections which required all who entered the room to use isolation precautions.

Staff S interviewed on 3/30/11 at 8:15pm acknowledged they assume staff placed patient #39 on isolation precautions at the time of admission.

Staff C interviewed on 3/30/11 at 10:00am acknowledged they were unaware of any current patients with communicable or infectious diseases. Staff C failed to provide investigative documentation that identified inpatient #39 with a transmittable infection, on antibiotic medications and isolation precautions.

- Patient #40's medical record reviewed on 3/30/11 revealed an admission date of 3/29/11 with a diagnosis of a cellulites abscess with a wound on the upper back. At admission the physician ordered Vancomycin IV (an antibiotic) for treatment of the wound infection.

Observation made on 3/30/11 at 4:30pm revealed patient #40 ' s room had a sign posted on the door that identified the patient had infections which required all who entered the room to use isolation precautions.

Staff S interviewed on 3/30/11 at 8:15pm acknowledged they assume staff placed patient #40 on isolation precautions at the time of admission.
Staff C interviewed on 3/30/11 at 10:00am acknowledged they were unaware of any current inpatients with transmittable infections. Staff C failed to provide investigative documentation that identified inpatient #40 with a transmittable infection, on antibiotic medications and isolation precautions.
- The "Infection Control Log" review on 3/30/11 between 10:00am and 11:00am lacked evidence of a plan to provide surveillance for healthcare workers with infections and communicable diseases.
Staff C interviewed on 3/30/11 at 10:00 to 11:00am confirmed the hospital lacked an surveillance program for personnel who report illness related to communicable or transmittable diseases. The hospital failed to have an active surveillance program that identified and investigated all infections and communicable diseases for patient and personnel.

Based on staff interview and record review the hospital ' s infection control officer failed to maintain a current log of patients who had or developed infections in order to identify a trend or outbreak, and infections identified through employee health services, monitor patients who meet the CDC (Center for Disease Control) criteria for requiring isolation precautions during their hospitalization. The log failed to include 3 of 3 sampled patients identified during the survey with infections and on isolation precautions (patient # ' s 9, 39 and 40). The failure for ongoing monitoring placed patients and healthcare workers at risk for healthcare acquired infection.

Findings include:

- Patient #9 ' s medical record reviewed on 3/30/11 at 7:00pm revealed an admission date of 3/23/11 with a diagnosis of possible pneumonia, urinary tract infection (UTI) and acute pharyigittis. Staff obtained the ordered admission culture which grew out Proteus Mirabilis (a species abundant in nature but that rarely grows in humans) in the urine and Methicillin Resistant Staph Aureus (MRSA - an infection-causing bacteria resistant to almost all antibiotics) in the patient ' s sputum. On 3/26/11 the culture result identified the patient with VRSA (Vancomycin-resistant Staphylococcus aureus , a strain of the bacterium Staphylococcus aureus). On 3/23/11 physician #1 ordered IV (intravenous) Rocephin (an antibiotic), on 3/24/11 ordered IV Vancomycin (an antibiotic) and on 3/26/11 ordered IV Tobramycin (an antibiotic).

The infection control log lacked documentation patient #9 was identified with an infection, monitored for administration of antibiotics and with isolation precautions.

Staff C interviewed on 3/30/11 at 10:00am acknowledged the infection control log failed to identify patient #9 as a patient identified and monitored for infections.

Patient #39 ' s medical record reviewed on 3/30/11 revealed an admission date on 3/28/11 with a diagnosis of acute pharyigittis and RSV (respiratory syncytial virus (RSV) is a virus that causes respiratory infections) positive. On 3/28/11 the physician ordered Ceftin (an antibiotic for an ear infection) and on 3/29/11 physician #1 discontinued the Ceftin and ordered Rocephin (an antibiotic).

The infection control log lacked documentation patient #39 was identified with an infection, monitored for administration of antibiotics and with isolation precautions.

Staff C interviewed on 3/30/11 at 10:00am acknowledged the infection control log failed to identify patient #39 as a patient identified and monitored for an infection.

- Patient #40 ' s medical record reviewed on 3/30/11 revealed an admission date of 3/29/11 with a diagnosis of a cellulites abscess with a wound on the upper back. At admission physician #6 ordered Vancomycin IV (an antibiotic) for treatment of the wound infection.

The infection control log lacked documentation patient #40 was identified with an infection, monitored for administration of antibiotics and a patient with isolation precautions.

Staff C interviewed on 3/30/11 at 10:00am acknowledged the infection control log failed to identify patient #40 as a patient identified and monitored for an infection.

- The Infections Report (Log) reviewed on 3/30/ 11 at 10:00am lacked staff review and analysis, from July 2010 through March 2011 or the last 9 months. Staff C interviewed on 3/30/11 at 10:00am confirmed the log lacked any review of infections or diseases and analysis of potential hospital infections or diseases from July 2010, August 2010, September 2010, October 2010, November 2010, December 2010, January 2011, February 2011, and March of 2011.

Staff C interviewed on 3/30/11 at 10:00am acknowledged they failed to enter patient ' s identified with infections in the infection control log since July 2010. Staff C confirmed the hospital infection control officer failed to log and monitor those identified with infections and with isolation precautions.

The Hospital failed to maintain a current infection control log.